(Users are advised to consult the supporting evidence for a
consideration of all the implications of a recommendation)

Infection is no longer a major cause of maternal or perinatal mortality in the
United Kingdom, but certain maternal infections may be transmitted to the infant.
Transmission may occur in utero, at the time of delivery or, in the case of HIV, during
breast feeding and may be the cause of congenital anomaly and/or fetal or perinatal
infection(i).

4.1a. 3-8% of women have
asymptomatic bacteriuria in pregnancy and about one third of these will, if untreated,
develop symptomatic infection. Screening followed by antibiotic therapyis
beneficial in reducing the development of symptomatic infection and its complications(i).(Health gain notation - 1 " beneficial")

4.3a. Screening for, and
appropriate antibiotictreatment of, chlamydia in pregnancy is likely to
be beneficial, especially as newer testing methods utilizing urine make testing more
acceptible to the pregnant woman(i,ii).

4.4c. Available data show that
administration of antibiotics in pregnancy is only temporary in eradication of
vaginal colonisation with Group B streptococci. Further trials are indicated(i)i.
(Health gain notation - 4 " unknown")

4.4d. While there is clear evidence
that treatment should be given to colonised women in labour there isinsufficient
evidence to recommend population screening for Group B streptococci in pregnancy
i.(Health gain notation - 4 "unknown")caveat: There is a need for rapid methods of diagnosis and a number of these
are currently under development.

4.5a. High risk screening only is
still performed in many areas but total population screening for the hepatitis B surface
antigen (HBsAg) is likely to be introduced shortly(i). (Health gain notation - 3 "trade-off between beneficial and adverse
effects")Where screening is carried out: Babies born to mothers who are HBeAg +ve, who are
HBsAg +ve without e markers (or where e marker status has not been determined), or who
have had acute hepatitis during pregnancy should receive HBIG as well as active
immunisations (to prevent development of active infection and possible liver tumours).
Hepatitis B vaccine, but not HBIG (Hep B immunoglobulin), is recommended for babies born
to mothers who are hepatitis B surface antigen +ve but known to be anti-HBe +ve(i,ii).(Health gain notation - 2 "likely to be beneficial")

4.6a. There is some evidence that Aciclovir
given to the woman with recurrent genital herpes simplex in pregnancy reduces viral
shedding at delivery, symptomatic relapses and the use of Caesarean section. Controlled
studies are underway(i,ii).(Health gain notation - 4 "unknown")

caveat: Experience
with the use of aciclovir in pregnancy is limited(ii)

4.7a. Both symptomatic and
asymptomatic women may transmit HIV. Offering counselling and screening to women
considered to be at high risk will detect only a proportion of infected women, thus
limiting optimum interventions in pregnancy in terms of zidovudine treatment, delivery and
infant feeding(i).(Health gain notation - 3 "trade-off between beneficial and adverse
effects")Current recommendations in the UK are for population screening in areas of
high prevalence (e.g. in London 1:580 pregnant women are HIV positive) as compared with
areas of low prevalence (1:9600 outside South East England)(ii).

4.7b. The evidence on whether
elective delivery by Caesarean Section reduces the risk of fetal transmission is
inconclusive(i) but one study suggests that this may be reduced (NNT = 12 Caesarean
sections to prevent infection in one infant)(ii).

4.7c. Zidovudine treatment is
likely to be beneficial in decreasing the risk of mother-to-child HIV infection(i)
(8.3% infants infected in the zidovudine group and 25.5% infected in the control group for
one trial)(ii), even at high viral loads(iii) but further trials are necessary.

4.7d. Transmission
of HIV through breast milk is a substantial added risk. It is estimated that breast
feeding doubles the risk of infection of the infant and should be avoided(i).(Health gain notation - 6 "likely to be harmful")

4.7e. If the mother has received
perinatal AZT treatment, infants should receive oral AZT for a total of 4-6 weeks,
then commence co- trimoxazole as prophylaxis against pneumocystis pneumonia, until the
infants HIV status has been determined(i).(Health gain notation - 2 "likely to be beneficial")

4.9a. Screening for Rubella
antibodies in pregnancy followed by postpartum vaccination of seronegative womenis good practice in reducing congenital anomaly in subsequent pregnancy(i).(Health gain notation - 2 "likely to be beneficial")

4.10a. The introduction of routine
screening for, and treatment of, syphilis in pregnancy antedated randomised
controlled trials. It remains currently good practice(i). Although the number
of cases is very small in the United Kingdom (6 cases in 1996) there is evidence of an
increase of syphilis among visitors to Eastern Europe(ii).

4.11a. Clotrimazole is beneficial
in the treatment of vaginal candida infection and associated with better compliance
and this should be used in preference to nystatin(i).(Health gain notation - 1 "beneficial")

4.13a. Metronidazole remains the drug
of choice for symptomatic trichomonal vaginitis in pregnancy. A single
oral dose of Tinidazole is effective (93% of women were free of infection after 4 weeks)
but should be avoided in the first trimester(i,ii).(Health gain notation - 1 "beneficial")caveat: warn patients about side effects and attempt to treat partners.